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Acute abdomen in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Nicole Fearing, William L. Holcomb
Appendicitis is the most common indication for nonobstetric surgery and occurs in 1/766 to 1/3000 pregnancies (18,19). There is no increased risk of appendicitis associated with pregnancy, but there is credible concern that the severity is increased in the pregnant patient. This may be due to the difficulty and delay of diagnosis during pregnancy. There are many common symptoms of pregnancy that may mimic appendicitis, such as nausea, vomiting, and round ligament pain. The leukocytosis of pregnancy may also obscure evaluation. It has also been previously reported that the anatomic location of the appendix changes with the growing uterus. More recent studies as noted previously in this chapter have refuted this idea and overall the appendix remains in its normal position. The diagnosis of appendicitis preoperatively in the pregnant patient has been reported in only one-half to three-fourth of the cases taken to the operating room (OR) (18,20,21). Finally due to the difficulty in diagnosis and the subjective reluctance of some to take a pregnant patient to the OR, the incidence of perforation is about 25% to 40% (18,21,22). This is even more concerning in light of the risk of fetal demise, which is 7% to 10% in the nonperforated appendicitis case and up to 24% if the appendix is perforated (18,22–24).
Anatomy & Embryology
Published in Manit Arya, Taimur T. Shah, Jas S. Kalsi, Herman S. Fernando, Iqbal S. Shergill, Asif Muneer, Hashim U. Ahmed, MCQs for the FRCS(Urol) and Postgraduate Urology Examinations, 2020
The fallopian tubes protrude upwards and lift the peritoneum into a fold known as the broad ligament that connects the sides of the uterus to the pelvic walls and floor. The cardinal (Mackenrodt’s) ligament is located in the base of the broad ligament and attaches the cervix to the lateral pelvic wall at the ischial spine and carries the uterine vessels. Each ovary sits in a fossa on the lateral wall of the pelvis surrounded by the external iliac vessels above, the internal iliac vessels and ureter behind and the obturator nerve in the floor. Each ovary is secured to a different structure by several ligaments; Mesovarium ligament – To the back of the broad ligament.Round ligament of ovary – To the side of the uterus by passing through the broad ligament.Suspensory ligament – To the pelvic side wall and carries the ovarian artery.
Advances in Adult Dysplasia
Published in K. Mohan Iyer, Hip Joint in Adults: Advances and Developments, 2018
In severe coxa valga, the fovea can be in cranial position and can even go under the WB area. As a result, the delta fovea angle tends to zero or even minus and the fovea may articulate with the lunate surface. This situation leads to a decreased WB surface area and the acceleration rate of OA. Also potentially, round ligament impingement may occur (Fig. 21.17) [60].
Isolated abdominal wall metastasis in early ovarian cancer: a true systemic metastasis or local tumour cells implantation
Published in Journal of Obstetrics and Gynaecology, 2019
Deepti Choudhary, Gopal Sharma, Taruna Singh, Nilokali Chishi, Pankaj Kumar Garg
Our case is unique, in that it is the only case diagnosed with abdominal wall metastasis in a stage IA ovarian cancer after surgical resection. Unlike the previously reported case by Haughney et al, there was no intra-operative tumour spillage (Haughney et al. 2001). Ascites was minimal at the index surgery (malignant cytology was negative) and no drains were placed intra-operatively. Unlike other case reports of recurrence at the previous low transverse incision site, this patient was operated through midline laparotomy. In a study by Kleppe et al, three pathways of lymphatic drainage of ovaries were described (Kleppe et al. 2015). Two major pathways via ovarian ligament and infundibulopelvic ligament, another minor pathway via round ligament into the inguinal nodes were also described. Our patient had a history of undergoing hysterectomy for a uterine fibroid through Pfannenstiel incision, the surgery was performed 10–years prior to the surgery for ovarian cancer. It might be possible that the Pfannenstiel incision had resulted into disruption of the lower abdominal wall lymphatics and led to aberrant localisation and proliferation of the tumour cells which might have been freed into the peritoneum due to microscopic intra-operative tumour spillage during surgery for ovarian cancer. We need to highlight that isolated AWM due to haematogenous spread is definitely another plausible cause but seems unlikely in this case due to the absence of metastatic deposits anywhere else in the body.
Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome
Published in Acta Chirurgica Belgica, 2019
C. H. Mazzetti, N. Hock, S. Taylor, J. Lemaitre, K. Crener, E. Lebrun
Herniation through a defect in the broad ligament was firstly reported by Quain in 1861 [3], in an autopsy series. Cilley classified broad ligaments defects in three categories in function of the site of laceration: type 1, the most common, occurs between fallopian tube and round ligament; type 2 between fallopian tube and ovary and type 3 between round ligament and uterus [4]. Hunt describes another type of hernia classification: fenestra type that involves a complete fenestration through both peritoneal layers, hernia sac is absent and the herniation is located lateral to the uterus and pouch type that involves only one of the layers, anterior or posterior, the herniation comes with a sac [5,6]. In female embryos, broad ligament origin from fusion of the paramesonephric ducts, but the physiopathology in congenital forms remains unknown. In nulliparous patients, it has been hypothesized that defect can result from spontaneous rupture of cystic structures remnants of mesonephric or mulleran ducts [4]. Acquired forms on the contrary seem to be due to trauma resulting from pregnancy or delivery (80% of cases have been identified in multiparous women), surgery, endometriosis or pelvic inflammatory disease [7,8].
Ovotestis at 18 years: an accidental discovery in an internally displaced persons’ camp in North-Eastern Nigeria
Published in Journal of Obstetrics and Gynaecology, 2019
Hadiza Abdullahi Usman, Bala Mohammed Audu, Mohammed Bukar, Ahmed A. Mayun
The breasts were Tanner stage 1 V with scanty feminine pubic hair. There was a ‘phallus’ that was about 5 cm long and 2 cm in diameter with an excess redundant hood and fused labia minora from about 2 cm above the urethral meatus (Figure 1(A)). There was an obvious right labio-scrotal fold with a palpable swelling (possibly a gonad) measuring 4 × 2 cm in diameter. The urethral meatus opened at the base of the ‘penile’ shaft immediately above the vaginal opening (Figure 1(B)). There were no palpable masses in the inguinal canals. A rectal examination revealed a uterus that was deviated to the left side. A pelvic ultrasound showed a uterus with an AP diameter of 20.8 mm with a late proliferative endometrium. The left ovary was visualised with a dominant follicle of 17 mm. The right ovary was, however, not seen. The Buccal smear and blood film Barr bodies were greater than 50%. A diagnostic laparoscopy revealed an acentric unicornuate uterus with a normal left tube and an ovary with features of ovulation. The right tube and ovary were not seen. The right round ligament was traced into the inguinal ring. Other investigations were within normal.